One common thread connects all aspects of patient engagement: To truly engage patients, we must communicate with them in health-literate ways so they can be active participants in their own care. For written materials (digital or print), that means using the principles of plain language. While there is a lot written about the need to use plain language, there is not a lot written about how to do it well. And anyone who has tried to do so knows that it involves much more than just simplifying words, taking things out, and running it through a readability calculator—there’s a nuance to writing effectively in plain language. In many ways, this is what I’ve done my whole professional life. For 15 years, I’ve been proud to call myself a plain-language lawyer. And, since 2012, I’ve focused most of my efforts on health literacy, health law, and clear health communication.

I’m often asked, “How do I move beyond the words to create a document that people can connect with and understand?” My answer typically revolves around three pillars needed to lay the foundation for clarity: audience, purpose and input.

1. Audience: Where will your intended audience be reading this document?

One of the tenets of patient engagement is to meet patients where they are. We can do this with written documents, too. But we first have to know who they are. After all, how do we know where they’ll be if we don’t take the time to consider who they are? For written documents, this involves considering who is your likely audience for this document and thinking about the context in which this audience will be reading it. For example, if you’re creating a document that largely targets single mothers raising young children, you know they are likely going to be reviewing documents in a hurry with a lot of chaos around them. If that is the case, then regardless of their health literacy, an easy-to-read document will not only help them understand; it will make their lives easier. What could be better than that?

2. Purpose: What is the goal of this document?

Whether I’m creating a consent form, a contract or a piece of education material, I start by thinking about the audience’s needs and the purpose of the document. Thinking about the audience alone misses the point for writing the document in the first place. Be specific with purpose – what is the goal of this specific document? Is it to educate the patient? Is it to protect an organization from liability? Is it some hybrid of the two? Another way of thinking about this is to consider how this document will be used in a health setting. That is, in what context will it be used? For example, is it part of a series of documents that will be given to the patient and this is just another one on the pile? Or is this the only piece of education material they will receive? Having the answers to questions like these are essential to creating a document that works—that engages.

3. Input: Whose information or feedback do you need to improve this document?

If you’re creating a document for someone else, you’ll likely need to get input about the document’s true purpose. When you do so, ask what a positive outcome would look like for this document? This question may make some people pause. Not many think of documents as vital to outcomes. But all documents are drafted (or should be) with a specific outcome, or range of outcomes, in mind.

For example, one outcome for a consent form is to legally protect the provider should the patient sue for lack of consent. But another entirely valid outcome could be to reduce the chances that someone even sees a lawyer in the first place. Think about that. If a patient has a procedure and some complication occurs that the patient did not fully understand, they are more likely to seek the advice of a lawyer because they didn’t know what they were agreeing to. But, on the other hand, if the patient clearly understood the risk of the complication that arose because of the clarity of the form, then they are more likely to accept responsibility for their consent and not see a lawyer in the first place. If that’s a positive outcome for the client, then simply listing the risk in legalistic language that most can’t understand will not be effective. You can only do this through clear, health-literate communication.

The other part of the “input” pillar is patient input. This involves user-testing the document. You cannot engage patients through written documents if you aren’t testing the documents with them. Of course, formal user-testing (or field-testing) with patients with low health literacy is the ideal way to figure out how patients will use and react to a written document. However, that is not always possible because of time constraints or budget concerns. In these cases, any form of user testing – user testing on a dime, as I call it – will do. User testing is so beneficial that any user-testing is better than none at all, yet many skip this step.

In the end, creating documents that are understandable and engage is hard work. There are many things to think about, from word choice to organization to document design. But the foundation for clarity—the pillars—are audience, purpose and input. Without considering these, your documents may score well on a readability calculator, but they may not engage.

Christopher Trudeau, JD, has a dual appointment as an associate professor in the UAMS Center for Health Literacy and as an associate professor of law at the UALR Bowen School of Law. Chris is an expert on health literacy, plain language and the law. His views are his own; they do not necessarily represent those of his employers. He may be reached at ctrudeau@uams.edu.

2 Comments

Hello,
we found this article useful. Here at Healthwatch East Riding, England we have a group of volunteers who proof read health based documents. Their views are then fed back to the document owner prior to publication.
Martin Davies
Project Officer

Thank you for the kind words. It is very good practice to have these volunteers read the documents. Do you also prompt them for places where they struggled? When I do this in user testing, I tend to frame the problem as my error — “As you read through this document, put stars next to the places where we’ve failed to clearly explain things.” For longer documents and webpages, I’ll also ask people to perform some task using it, what I call task-based user testing. That can be very helpful for organization or navigation issues.